Maximizing recovery after cardiac events

Roughly 735,000 Americans have a heart attack each year—some with a related
cardiac arrest—including 525,000 for the first time, according to American
Heart Association data. Some recent studies, by measuring quality of life and other
effects, are striving to provide better insights into how well these patients navigate
their postrecovery lives.

One study, published in 2016 in the Journal of the American College of Cardiology, provided encouraging news for patients who survive and out-of-hospital cardiac arrest
and are discharged from the hospital (and not to hospice). The mortality rate during
the subsequent first year was similar for those who had experienced a cardiac arrest
along with a myocardial infarction (MI) compared with an MI alone—13.8% versus
15.8% for the latter group, according to data from 54,860 patients ages 65 years and
older.

“We were actually surprised that we found that in fact the patients with cardiac
arrest, once we get them through the hospital, those who survive actually do quite
well relatively speaking,” said Christopher Fordyce, MD, a clinical assistant
professor in the division of cardiology at the University of British Columbia in Vancouver.

But another key milestone, returning to work, has been more difficult for cardiac
arrest survivors to reach, according to a study involving European patients that was
published in January in Circulation: Cardiovascular Quality and Outcomes.

Among those individuals who survived a cardiac arrest, 46.5% returned to their prior
level of work. An additional 22.5% also resumed employment, albeit at reduced hours.
But a matched group of heart attack survivors fared better; 72% returned to their
prior work lives and another 8% did so but at reduced hours.

In addition, a recent study published June 12 by Circulation: Cardiovascular Quality and Outcomes looked at 9,319 patients who had had an MI and found that those who had more unplanned
admissions, postdischarge bleeding complications, hypertension, and smoking were more
likely to have an adverse change in employment at one year. This group was more likely
to be depressed, to have lower health status, and to report moderate to extreme financial
hardship in medication costs, the study authors found.

Job-related insights

Better understanding patients' heart recovery trajectory, and whether it differs between
genders, has been one of the focuses of Yale University researcher Rachel Dreyer,
PhD.

“An MI is a life-changing event,” said Dr. Dreyer, an assistant professor in the department of emergency medicine at
Yale who coauthored an editorial accompanying the Circulation: Cardiovascular Quality and Outcomes study. “It's accompanied by a complex set of emotional reactions that can pose
barriers to successful recovery and functioning and their ability to resume employment. ”

In one of Dr. Dreyer's own studies, she and her colleagues looked at the likelihood
of younger heart attack patients, ages 18 to 55 years, returning to work. The men
in the group of 1,680 patients were slightly more likely, 89%, versus 85% among the
women, according to the findings, which were published in 2016 in Circulation: Cardiovascular Quality and Outcomes.

The difference didn't prove to be statistically significant after adjustment for socioeconomics,
health status, and other factors. Still, Dr. Dreyer wants to learn more about the
14% overall of men and women who did leave the workforce. What physical and other
factors led them to drop out?

Dr. Dreyer and her colleagues did flag a few patterns. Those who didn't return to
work were less likely to be married and more likely to work a manual job and enjoy
less robust health prior to their heart attack. Women specifically may be coping with
symptoms that might make it more difficult to work, said Dr. Dreyer, citing a prior
2015 study she was involved with, published in Circulation.

That study, which relied on the same dataset of younger heart attack patients, looked
at symptoms and quality of life during the first post-MI year. Researchers found that
women experienced more physical and mental symptoms and reported more angina and generally
a lower quality of life than their male counterparts.

Cardiac rehab gaps

During those first few months after a scary heart crisis, cardiac rehabilitation sessions
can help bolster patients mentally as well as physically, said Kelsey Flint, MD, a
cardiologist and an assistant professor of medicine at the VA Eastern Colorado Health
Care System in Denver.

“Patients often feel very timid in every aspect of their life afterward,”
Dr. Flint said. “Speaking more from anecdotal experience, I find that cardiac
rehab really helps patients regain their confidence after a big event such as a heart
attack.”

But Dr. Flint worries that too often more frail patients might be unnecessarily missing
out. She was the lead author on an observational study, published Feb. 24 in the Journal of the American Heart Association, that looked at death and disability after one year among 329 patients ages 65 years
and older.

Those with slower gait speeds got the same benefits from cardiac rehabilitation as
those who were able to walk faster. (The speed, assessed during a prior study based
on a home assessment, translated to less than 1.8 miles per hour, roughly similar
to someone “slowly making it around their house,” Dr. Flint said.) But
the slower walkers reported they had been less likely to have been encouraged to participate—55.7%
versus 68.9% for those with faster gaits.

In the end, only 27.1% of those individuals with slow gaits joined the rehab sessions
versus 40.1% of the faster walkers. “The implication there is that we, meaning
cardiology and primary care providers, should still consider encouraging patients
to participate in cardiac rehab even if we perceive them to be frail,” Dr.
Flint said.

The study also highlighted other potential socioeconomic vulnerabilities, Dr. Flint
noted. Those older individuals with slow gait speeds who didn't enroll in cardiac
rehab were more likely to be female, nonwhite, unmarried, and less educated.

Unseen stressors

With those social factors in mind, doctors should look out for sometimes hidden barriers
to recovery, Dr. Flint said. Figure out if the rehabilitation facility's location
is too far away, or the patient lacks a way to get there, she said. Get a key family
member involved in the patient's recovery by joining appointments, even if it's only
by speakerphone for those unable to break away from work or another commitment.

When a patient lobbies to return to work, and the job involves manual labor, Dr. Flint
pushes even more fiercely for cardiac rehabilitation first, so the strain of exertion
can be monitored in a controlled setting. “Because then cardiac rehab nurses
and physiologists can give me feedback on how the patient is doing,” she said.

Meanwhile, depression, anxiety, and other mental health struggles can inhibit recovery
in ways that are still being understood. One recent study involving nearly 25,000
U.S. patients diagnosed with a heart attack or angina looked at mortality rates for
those subsequently diagnosed with depression. During a follow-up period of nearly
a decade, 50% of those with depression died compared with 38% without, according to
the 2017 study published in European Heart Journal: Quality of Care & Clinical Outcomes.

Anthony Pavlo, PhD, a clinical psychologist at Yale who is working with Dr. Dreyer
on her cardiovascular research, said that heart attack survivors might be coping with
everything from a feeling of health vulnerability and concerns about their sexuality
to various forms of self-blame that can inhibit their recovery. Did they work too
hard? Was their poor diet the culprit?

Meanwhile, Dr. Pavlo said, “The sort of care that they're given afterwards
[by clinicians] is all focused on those things that they might be blaming themselves
for.” And, he added, “No one is really saying, ‘Well, how are
you doing with all of this?’”

One approach is for physicians to pose open-ended questions to gauge the patient's
state of mind, Dr. Pavlo said, such as “What's going on? What are you most
worried about these days?”

Above all, physicians should keep their radar attuned to why a patient may appear
to be nonadherent to rehab or therapy after a cardiac event, because there is frequently
something else going on, Dr. Pavlo said.

Even if patients don't meet diagnostic criteria for depression or another mental health
issue, they may be walking around demoralized and even subconsciously braced for that
next heart crisis, he said. “If someone is not feeling hopeful, they are not
going to go to cardiac rehab. What's the point?”

Instead of just handing over a depression screen, Dr. Pavlo said, the doctor can provide
some broader context. “You can say, ‘Often people might get depressed
after a heart attack. It is a life-changing event and that's why we're doing this
screen.’ It doesn't take a lot of time [to say], and people get it.”

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